Peptic ulcer disease/ Epigastric pain

PEPTIC ULCER DISEASE- EPIGASTRIC PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Peptic Ulcer Disease- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Epigastric pain, epidemiology, etiopathogenesis, clinical features, investigations, complications and treatment of Peptic Ulcer Disease.
• I have also included a mind map and a treatment algorithm for Peptic Ulcer Disease.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.

1. PEPTIC ULCER DISEASE EPIGASTRIC PAIN AN OVRVIEW Dr.B.Selvaraj MS;Mch;FICS ; “Surgical Educator” Malaysia

2. PEPTIC ULCER DISEASE Different causes for epigastric pain Applied Basic Sciences Etiopathogenesis Epidemiology Clinical features Investigations Complications Treatment Mindmap Treatment Algorithm

3. PEPTIC ULCER DISEASE D/D for Epigastric Pain

4. PEPTIC ULCER DISEASE Applied Anatomy Celiac Axis: Left Gastric Common Hepatic Splenic -Rt Gastric from Hepatic artery proper -Rt Gastroepiploic from Gastroduodenal -Short Gastric from Splenic artery

5. PEPTIC ULCER DISEASE Applied Physiology Chief cells Pepsinogen Parietal cells Hydrochloric acid and intrinsic factor G cells Gastrin D cells Somatostatin Intrinsic factor is needed for the absorption of Vit B12 Autoimmune destruction of parietal cells causes deficient B12  Pernicious Anemia 1. Gastrin from G cells 2. Acetylcholine from vagus nerve 3. Histamine from paracrine release via mast cells

6. PEPTIC ULCER DISEASE ETIOPATHOGENESIS

7. PEPTIC ULCER DISEASE ETIOPATHOGENESIS

8. PEPTIC ULCER DISEASE EPIDEMIOLOGY A peptic ulcer is a break in the epithelial surface of the stomach or duodenum caused by the action of gastric secretions (acid and pepsin) and infection with Helicobacter pylori. Mucosal infection with Helicobacter pylori is a major cause for PUD Patients with duodenal ulcers have an increased capacity for gastric acid secretion relative to normal people. Hemorrhage is the leading cause of death associated with peptic ulcer. Each year, approximately 300,000 t o 500,000 new cases of PUD occur. Three to four million patients are self-medicating for symptoms of PUD 30,000 surgeries are performed annually for PUD . The incidence and prevalence of PUD varies based upon the presence of Helicobacter pylori (H. pylori). Higher rates are found in countries where H. pylori infection is higher DUs occur two decades earlier than GUs, particularly in males .

9. PEPTIC ULCER DISEASE

10. PEPTIC ULCER DISEASE Clinical Features Symptoms of Gastric ulcers Male : female 3:1, peak incidence 50+ years. Epigastric pain induced by eating. Aversion to food because of pain Nausea or vomiting. Hemetemesis and Melenemesis common Weight loss. Dyspepsia: Bloating and early satiety Heartburn, which is a burning sensation in the chest Anemia from chronic blood loss.

11. PEPTIC ULCER DISEASE Clinical Features Symptoms of Duodenal ulcers and Type 2 Gastric ulcers Male : female 1:1, peak incidence 25–50 years. Epigastric pain during fasting (hunger pain), relieved by food/antacids, often nocturnal, typically exhibits periodicity (i.e. recurs at regular intervals). Nausea or vomiting. Weight gain. Dyspepsia: Bloating and early satiety Boring back pain if ulcer is penetrating posteriorly Haematemesis from ulcer penetrating gastroduodenal artery posteriorly. Peritonitis if perforation occurs with anterior DU. Vomiting if gastric outlet obstruction (pyloric stenosis) occurs (note succussion splash and watch for hypokalaemic , hypochloraemic alkalosis).

12. PEPTIC ULCER DISEASE Duodenal Ulcer Vs Gastric Ulcer

13. PUD- INVESTIGATIONS Upper GI Endoscopy Upper GI Endoscopy “ Most sensitive and specific test”

14. PUD- INVESTIGATIONS Upper GI Endoscopy Benign Gastric Ulcer Malignant Gastric Ulcer Resected Specimen

15. PUD- INVESTIGATIONS H.Pylori Testing NON-INVASIVE INVASIVE H. pylori is a helical gram-negative rod with flagella that resides beneath the mucous layer of stomach & duodenum Production of the enzyme urease allows H. pylori to survive in the acidic environment of the stomach.

16. PUD- INVESTIGATIONS Contrast Radiology Upper gastrointestinal radiology is not used as much as in previous years, as endoscopy is a more sensitive investigation Computed tomography (CT) imaging with oral contrast has also replaced contrast radiology where anatomical information is sought, eg large hiatus hernias of the rolling type

17. PUD- COMPLICATIONS Four major complications of peptic ulcer disease (PUD) - Bleeding, -Perforation, -Penetration, -Obstruction.

18. PUD- TREATMENT PPls are the gold standard with80 to-90% healing at 8 weeks (e.g. omeprazole, lansoprazole). H2 antagonists have a high recurrence rate eg. Cimetidine , Ranitidine PPIs need acidic environment to get activated. So, shouldn’t combine with antacids and H-2 blockers Acid neutralizing & inhibitory drugs

19. PUD- TREATMENT Cyto -Protective Drug H.Pylori Eradication H.Pylori should be eradicated in all patients with documented PUD No single drug is effective in eradication Combination of drugs should be given for 14 days Triple therapy : H. pylori eradication ( Rx:amoxicillin 500 mg,and clarithromycin 500 mg) and PPI (20 mg omeprazole or 30 mg lansoprazole b.d. ) for 7–14 days. Metronidazole may replace amoxicillin in penicillin-allergic patients. Quadruple therapy : bismuth, metronidazole, tetracycline and PPI for 7–14 days. The test of choice for documenting eradication is Urea breath test

20. PUD- TREATMENT - SURGERY Elective for intractable GU: Billroth I gastrectomy . Normal vagal innervation of stomach

21. PUD- TREATMENT - SURGERY Elective for intractable DU: Highly selective vagotomy Selective Vagotomy Truncal Vagotomy

22. PUD- TREATMENT - SURGERY Pyloric stenosis: Truncal vagotomy + Gastrojejunostomy Truncal Vagotomy + Pyloroplasty

23. PUD- TREATMENT - SURGERY Gastric & duodenal ulcer perforation For DU Perforation- Graham’s omentopexy+Peritoneal toileting For GU Perforation- Graham’s omentopexy + Biopsy of the ulcer + Peritoneal toileting

24. PUD- TREATMENT - SURGERY Gastric & duodenal ulcer bleeding

25. PEPTIC ULCER DISEASE MINDMAP

26. PEPTIC ULCER DISEASE TREATMENT ALGORITHM

27. PEPTIC ULCER DISEASE TREATMENT ALGORITHM

28. Peripheral Arterial Diseases(PAD)